Background
Septic thrombophlebitis is a condition characterized by venous thrombosis, inflammation, and bacteremia.[1] The clinical course and severity of septic thrombophlebitis are quite variable. Many cases present as benign, localized venous cords that resolve completely with minimal intervention. Some cases present as severe systemic infections culminating in profound shock that is refractory to aggressive management, including operative intervention and intensive care. (See Presentation and Prognosis.)
A number of distinct clinical conditions have been identified, depending on the vessel involved, but all thrombophlebitides involve the same basic pathophysiology. Thrombosis and infection within a vein can occur throughout the body and can involve superficial or deep vessels. Notable examples are thrombophlebitis in the following (see Etiology):
Peripheral septic thrombophlebitis is a common problem that can develop spontaneously but more often is associated with breaks in the skin. Though most commonly caused by indwelling catheters, septic thrombophlebitis may also result from simple procedures such as venipuncture for phlebotomy and intravenous injection. While infection must always be considered, catheter-related phlebitis can result from sterile chemical or mechanical irritation. (See Etiology.)
Septic phlebitis of a superficial vein without frank purulence is known as simple phlebitis. Simple phlebitis is often benign, but when it is progressive, it can cause serious complications, and even death.
Suppurative superficial thrombophlebitis is a more serious condition that can lead to sepsis and death, even with appropriate aggressive intervention.[2] A frequent complication is embolization of infected thrombus to distant sites, most commonly the lungs, leading to septic pulmonary emboli, hypoxia, sepsis, and often death.[3] Patient factors such as burns,[4] steroid usage,[5] or intravenous drug use[3] increase the risk of developing septic phlebitis and its complications.
Septic phlebitis of the deep venous system is a rare, but life-threatening, emergency that may fail to respond to even the most aggressive therapy. Any vessel can theoretically be involved, but the more common entities are detailed below.
Septic thrombophlebitis of the IVC or SVC is primarily the result of central venous catheter placement, with increased incidence in burn patients and those receiving total parenteral nutrition.[6] Patients are generally very ill appearing with high fever, and they may also have signs of venous occlusion, including arm and neck edema. The mortality rate of these infections is high, but cases of successful treatment have been reported.[6]
Lemierre syndrome is a suppurative thrombophlebitis of the internal jugular vein caused by oropharyngeal infections such as tonsillitis and dental infections. Spread of the infection into the parapharyngeal space that houses the carotid sheath leads to local inflammation and thrombosis of the jugular vein. Lemierre syndrome is easily missed and is more common than is generally appreciated.[7, 8] Unlike superficial vein thrombophlebitis, septic pulmonary emboli are nearly always present and lead to grave complications such as empyema, lung cavitation, and hypoxemia. Less commonly, septic emboli may traverse a patent foramen ovale and cause distant metastatic infections such as septic arthritis, osteomyelitis, and hepatic abscesses.[9]
Septic pelvic thrombophlebitis and ovarian vein thrombophlebitis are seen principally as a complication of puerperal uterine infections, such as endometritis and septic abortion.[10] Rarely, pelvic phlebitis may result from severe pelvic inflammatory disease or progressive infection of the urinary tract. In abdominal infections, such as appendicitis and diverticulitis, infection may spread to cause neighboring septic phlebitities.
Thrombophlebitis of the intracranial venous sinuses is a particularly serious problem and can involve the cavernous sinus, the lateral sinus, or the superior sagittal sinus. Cavernous sinus thrombophlebitis is caused by infection of the medial third of the face known as the "danger zone," ethmoid and sphenoid sinusitis, and, occasionally, oral infections. Mastoiditis and otitis media are rarely associated with septic phlebitis of the lateral sinuses, while thrombophlebitis of the superior sagittal sinus is the rarest and is primarily associated with meningitis. More than a third of cases of intracranial septic thrombophlebitis are fatal.[11]
A number of distinct clinical conditions have been identified, depending on the vessel involved, but all thrombophlebitides involve the same basic pathophysiology. Thrombosis and infection within a vein can occur throughout the body and can involve superficial or deep vessels. Notable examples are thrombophlebitis in the following (see Etiology):
- Peripheral veins
- Pelvic veins
- Portal vein (pylephlebitis)
- Superior vena cava (SVC) or inferior vena cava (IVC)
- Internal jugular vein (Lemierre syndrome)
- Dural sinuses
Peripheral septic thrombophlebitis is a common problem that can develop spontaneously but more often is associated with breaks in the skin. Though most commonly caused by indwelling catheters, septic thrombophlebitis may also result from simple procedures such as venipuncture for phlebotomy and intravenous injection. While infection must always be considered, catheter-related phlebitis can result from sterile chemical or mechanical irritation. (See Etiology.)
Septic phlebitis of a superficial vein without frank purulence is known as simple phlebitis. Simple phlebitis is often benign, but when it is progressive, it can cause serious complications, and even death.
Suppurative superficial thrombophlebitis is a more serious condition that can lead to sepsis and death, even with appropriate aggressive intervention.[2] A frequent complication is embolization of infected thrombus to distant sites, most commonly the lungs, leading to septic pulmonary emboli, hypoxia, sepsis, and often death.[3] Patient factors such as burns,[4] steroid usage,[5] or intravenous drug use[3] increase the risk of developing septic phlebitis and its complications.
Septic phlebitis of the deep venous system is a rare, but life-threatening, emergency that may fail to respond to even the most aggressive therapy. Any vessel can theoretically be involved, but the more common entities are detailed below.
Septic thrombophlebitis of the IVC or SVC is primarily the result of central venous catheter placement, with increased incidence in burn patients and those receiving total parenteral nutrition.[6] Patients are generally very ill appearing with high fever, and they may also have signs of venous occlusion, including arm and neck edema. The mortality rate of these infections is high, but cases of successful treatment have been reported.[6]
Lemierre syndrome is a suppurative thrombophlebitis of the internal jugular vein caused by oropharyngeal infections such as tonsillitis and dental infections. Spread of the infection into the parapharyngeal space that houses the carotid sheath leads to local inflammation and thrombosis of the jugular vein. Lemierre syndrome is easily missed and is more common than is generally appreciated.[7, 8] Unlike superficial vein thrombophlebitis, septic pulmonary emboli are nearly always present and lead to grave complications such as empyema, lung cavitation, and hypoxemia. Less commonly, septic emboli may traverse a patent foramen ovale and cause distant metastatic infections such as septic arthritis, osteomyelitis, and hepatic abscesses.[9]
Septic pelvic thrombophlebitis and ovarian vein thrombophlebitis are seen principally as a complication of puerperal uterine infections, such as endometritis and septic abortion.[10] Rarely, pelvic phlebitis may result from severe pelvic inflammatory disease or progressive infection of the urinary tract. In abdominal infections, such as appendicitis and diverticulitis, infection may spread to cause neighboring septic phlebitities.
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